The nurse working in a long-term care facility is talking with a client diagnosed with congestive heart failure, diabetes, hypertension, and chronic renal failure, and notes mild edema of the ankles while the client is sitting in the chair
Breath sounds are clear and equal, with good chest excursion, and the client denies any feeling of shortness of breath. The nurse reviews the medical record and sees no significant change in the client's daily weights over the last week. What are the nurse's priority interventions for this client? Select all that apply. Standard Text: Select all that apply. 1. Call the doctor for an order to increase the client's diuretic.
2. Review the client's diet to determine sodium intake.
3. Review the client's BUN and creatinine.
4. Encourage the client to elevate her feet when sitting.
5. Apply antiembolism stockings.
4,5
Rationale: The client's edema is unlikely to be due to fluid retention if daily weights have been stable, so the nurse's interventions are aimed at promoting venous return to the heart by having the client elevate her legs and applying antiembolism stockings. While reviewing the diet and lab values are not wrong, it is unlikely that the client is experiencing fluid retention or that daily weights would be increased. There is no need to increase the client's diuretic dosage.
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